International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198 Int J Case Rep Images 2018;9:100982Z01QD2018. www.ijcasereportsandimages.com Du et al. 1 CLINICAL IMAGE PEER REVIEWED | OPEN ACCESS Air embolism Qian Du, Chak Kwan Tong CASE REPORT A 63-year-old man suffered from severe musculoskeletal deformity due to scoliosis, left renal stone, old stroke and on long term nasogastric tube. He presented with hydronephrosis, urosepsis, pneumonia, septic shock and gastrointestinal bleeding. His heart rate was 145 bpm and blood pressure was 88/67 mmHg, and his hemoglobin dropped from 180 g/L to 108 g/L after 700 ml bloody gastric fluid drainage from the nasal gastric tube. Then he underwent right axillary vein catheter insertion which showed central venous pressure (CVP) was only 2 mmHg, upper endoscopy and percutaneous left nephrostomy. He became hemodynamically very unstable, his heart rate dropped to 40 bpm, his blood pressure dropped to 60/30 mmHg,and noradrenaline was incresed from 0.55 ug/kg/min to 2.2 ug/kg/min to maintain MAP>65 mmHg. CT was repeated showing systemic air embolism. We detected air emboli in the pulmonary artery and aorta (Figure 1), right atrium (Figure 2) and right scapula and vertebral arch. His CT brain revealed intraparenchymal gas and diffuse edema (Figure 3). Agitated saline test did not reveal any right to left shunt on Transesophageal Echocardiogram study. Mediastinum appeared unremarkable on contrast CT Thorax, except for the presence of an esophageal diverticulum. Unfortunately, no definite cause could be attributed for the air embolism although each of the invasive procedure that he received posed the risk. This patient’s BAL culture and blood culture both yielded MDRPA, and pus from percutaneous nephrostomy Qian Du 1 , Chak Kwan Tong 2 Affiliations: 1 Assistant Consultant, Adult Intensive Care Med- icine Department, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China; 2 Consult- ant, Adult Intensive Care Medicine Department, The Univer- sity of Hong Kong-Shenzhen Hospital, Shenzhen, Guang- dong Province, China. Corresponding Author: Qian Du, The University of Hong kong-Shenzhen Hospital, Shenzhen, Guangdong Province, 518000; China; Email: [email protected]Received: 25 September 2018 Accepted: 12 November 2018 Published: 14 December 2018 yielded mycobacterium tuberculosis. His clinical condition declined progressively and had passed away after nine days. DISCUSSION Air embolism is an uncommon, but potentially catastrophic, event that occurs as a consequence of the entry of air into the vasculature. Air embolism can be venous or arterial. Surgery, trauma, vascular interventions, and barotrauma from mechanical ventilation and diving are the most common causes of air embolism [1–5]. The diagnosis is best made by demonstrating air in the intravascular space or organs Figure 1: Air in the Right Pulmonary Artery (R-PA) and Aorta (AO). Figure 2: Air in the Right Atrium (RA).
Transcript
International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198
Int J Case Rep Images 2018;9:100982Z01QD2018. www.ijcasereportsandimages.com
Du et al. 1
CLINICAL IMAGE PEER REVIEWED | OPEN ACCESS
Air embolism
Qian Du, Chak Kwan Tong
CASE REPORT
A 63-year-old man suffered from severe musculoskeletal deformity due to scoliosis, left renal stone, old stroke and on long term nasogastric tube. He presented with hydronephrosis, urosepsis, pneumonia, septic shock and gastrointestinal bleeding. His heart rate was 145 bpm and blood pressure was 88/67 mmHg, and his hemoglobin dropped from 180 g/L to 108 g/L after 700 ml bloody gastric fluid drainage from the nasal gastric tube. Then he underwent right axillary vein catheter insertion which showed central venous pressure (CVP) was only 2 mmHg, upper endoscopy and percutaneous left nephrostomy. He became hemodynamically very unstable, his heart rate dropped to 40 bpm, his blood pressure dropped to 60/30 mmHg,and noradrenaline was incresed from 0.55 ug/kg/min to 2.2 ug/kg/min to maintain MAP>65 mmHg. CT was repeated showing systemic air embolism. We detected air emboli in the pulmonary artery and aorta (Figure 1), right atrium (Figure 2) and right scapula and vertebral arch. His CT brain revealed intraparenchymal gas and diffuse edema (Figure 3). Agitated saline test did not reveal any right to left shunt on Transesophageal Echocardiogram study. Mediastinum appeared unremarkable on contrast CT Thorax, except for the presence of an esophageal diverticulum. Unfortunately, no definite cause could be attributed for the air embolism although each of the invasive procedure that he received posed the risk. This patient’s BAL culture and blood culture both yielded MDRPA, and pus from percutaneous nephrostomy
Qian Du1, Chak Kwan Tong2
Affiliations: 1Assistant Consultant, Adult Intensive Care Med-icine Department, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China; 2Consult-ant, Adult Intensive Care Medicine Department, The Univer-sity of Hong Kong-Shenzhen Hospital, Shenzhen, Guang-dong Province, China.Corresponding Author: Qian Du, The University of Hong kong-Shenzhen Hospital, Shenzhen, Guangdong Province, 518000; China; Email: [email protected]
Received: 25 September 2018Accepted: 12 November 2018Published: 14 December 2018
yielded mycobacterium tuberculosis. His clinical condition declined progressively and had passed away after nine days.
DISCUSSION
Air embolism is an uncommon, but potentially catastrophic, event that occurs as a consequence of the entry of air into the vasculature. Air embolism can be venous or arterial. Surgery, trauma, vascular interventions, and barotrauma from mechanical ventilation and diving are the most common causes of air embolism [1–5]. The diagnosis is best made by demonstrating air in the intravascular space or organs
Figure 1: Air in the Right Pulmonary Artery (R-PA) and Aorta (AO).
Figure 2: Air in the Right Atrium (RA).
International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198
Int J Case Rep Images 2018;9:100982Z01QD2018. www.ijcasereportsandimages.com
Du et al. 2
in a patient with a known risk factor for air embolism. Regardless of the mechanism responsible for the embolism, rapid and aggressive treatment is essential to preserve life and function [6]. For venous gas embolism, the mainstays of treatment are the prevention of further entry of gas, volume expansion, the administration of 100 percent oxygen, often with ventilatory support; positive inotropic support; and cardiopulmonary resuscitation, if necessary. For arterial gas embolism, hyperbaric oxygen is the treatment of choice, as soon as cardiopulmonary stabilization has been achieved. Massive venous and arterial air embolism is rare within most of the reported cases. Our case demonstrated an air embolism associated with large air pockets in the right atrium, pulmonary artery, aorta and cerebral parenchyma.
CONCLUSION
Air embolism should always be suspected when patients experience sudden-onset respiratory distress (venous air embolism) and/or experience a neurological event (arterial embolism) in the setting of a known risk factor (eg, surgery, trauma, vascular interventions, esophagogastroduodenscopy).
REFERENCES
1. Murphy BP, Harford FJ, Cramer FS. Cerebral air embolism resulting from invasive medical procedures. Ann Surg 1985 Feb;201(2):242–5.
2. Dudney TM, Elliott CG. Pulmonary embolism from amniotic fluid, fat, and air. Prog Cardiovasc Dis 1994 May–Jun;36(6):447–74.
3. King MB, Harmon KR. Unusual forms of pulmonary embolism. Clin Chest Med 1994 Sep;15(3):561–80.
4. Schmitt HJ, Hemmerling TM. Venous air emboli occur during release of positive end-expiratory pressure and repositioning after sitting position surgery. Anesth Analg 2002 Feb;94(2):400–3.
5. Heckmann JG, Lang CJ, Kindler K, Huk W, Erbguth FJ, Neundörfer B. Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization. Crit Care Med 2000 May;28(5):1621–5.
6. Muth CM, Shank ES. Gas embolism. N Engl J Med 2000 Feb 17;342(7):476–82.
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Keywords: Gastrointestinal bleeding, Septic shock, Systemic air embolism
How to cite this article
Du Q, Tong CK. Air embolism. Int J Case Rep Images 2018;9:100982Z01QD2018.
Article ID: 100982Z01QD2018
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doi: 10.5348/100982Z01QD2018CL
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Author ContributionsQian Du – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be publishedChak Kwan Tong – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone.
Consent StatementWritten informed consent was obtained from the patient for publication of this clinical image.
Figure 3: Air in brain parenchymal (arrows).
International Journal of Case Reports and Images, Vol. 9, 2018. ISSN: 0976-3198
Int J Case Rep Images 2018;9:100982Z01QD2018. www.ijcasereportsandimages.com
Du et al. 3
Conflict of InterestAuthors declare no conflict of interest.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
